Why Your Patient Isn’t Just Drunk

Let’s start off with a scenario that I am sure all of us are familiar with. You and your partner are dispatched to a reported fall outside of a bar at 0100. As you arrive to the scene, you see an approximate 35 year old staggering around with blood noted on his forehead. The patient tells you that he “only had a couple of beers” and “just lost [his] footing”. He denies any loss of consciousness or neck/back pain. The only visible trauma is a 2” laceration on the right-side of the forehead and you have controlled the bleeding. As you begin to assess the patient’s mentation, he is answering all of your questions appropriately, his vital signs are stable, and he denies any medical hx, current medications, or allergies. You and your partner attempt to coax the patient into moving into the back of the ambulance for further examination. The patient repeatedly tells you “I’m fine” and is refusing further examination and transport to the hospital. Do you allow this patient to refuse?

SOBRIETY V. INTOXICATION

So is merely drinking “a few beers” grounds for calling someone intoxicated? At what point can we call someone intoxicated and use the rules of implied consent in treating patients even against their expressed wishes? After scanning several different definitions of intoxication, there are a few disparities. Definitions like this: “a state in which a person’s normal capacity to act or reason is inhibited by alcohol or drugs” (Encyclopedia of American Law) are widely accepted, but where does that leave us? Obviously, these situations are handled differently depending on your medical direction, but here are some things to consider. Sure, your patient may be able to answer all of your questions appropriately, but what is their environment like? What are the chances that if you leave this patient exactly where you found them, that the patient or someone around them will be harmed? What is your patient’s speech like? Are they slurring or able to speak without difficulty? What is their motor function? Are they able to walk with steady gait? Are they aware of their surroundings, or are they going to wander off into traffic without intervention? Is there a chance that maybe their alcohol consumption could be masking other problems?

ALCOHOL, BLOOD, AND HYPOVOLEMIA

Alcohol does two different things to the cardiovascular system. It inhibits platelet aggregation as well promotes platelet aggregation. Yes, you just read that correctly. Alcohol accomplishes two polar opposite things within the blood stream. A way of looking at it is that platelets stick together in the bloodstream from consistent alcohol consumption leaving the chronic alcohol drinker with a higher risk of stroke, MI, PE, etc. The problem from platelet aggregation inhibition comes when there is a source of bleeding within the body whether due to a traumatic or a medical cause. A study linked here, shows that alcohol can actually “inhibits platelet adhesion to fibrinogen-coated surface under flow”.

So once your chronic alcohol drinker starts to bleed, it is very difficult to get said bleeding under control, BUT that’s assuming that you have discovered the bleeding to begin with. Anyone that has been in the field for any length of time should have a healthy fear and reverence for the intoxicated patient that has fallen and struck their heads. Even if not recently, immediate signs of brain hemorrhage can lie dormant, and for the patient that is potentially already altered, the subtle changes could easily be masked. Due to the corrosive nature of alcohol, chronic drinkers are much more likely to develop intestinal bleeding. There is a communal eyeroll anytime someone complains of hematemesis or melena, but for alcoholics, this is a potentially life-threatening problem that is often blown off in the emergency department and in the prehospital world. Hypovolemia whether due to blood loss or sheer volume depletion because of vomiting from conditions like pancreatitis or being on diuretics like lactulose (commonly prescribed for patients with cirrhosis to assist in filtering out toxins within the body) is a common problem that needs to be addressed. Was that a long enough run-on sentence for you? I promise I can do better.

ALCOHOL: THE GREAT DECEIVER

Let’s roll with another scenario here. You and your partner are dispatched to a report of an unconscious party at a private residence. A landlord went over to check in on a tenant and found him “unresponsive” on the ground. The patient is bradypneic and is unable to awake with painful stimuli. The patient wreaks of ETOH, but can you definitely say that this patient is just intoxicated? Can you as a prehospital provider state that the patient did not suffer a cardiac, neurologic, or diabetic event? Can you definitively say that there are no other intoxicating agents onboard; i.e. barbiturates, opiates, etc? Obviously, being unable to prove a life-threatening problem is not a reason to suspect that every intoxicated patient is suffering from one, but as critical thinkers prehospital providers have to be on the lookout for deterioration. We are not advocating for cookbook medicine or performing innumerable diagnostic tests for the sake of doing them, but when clinical and vital signs are not adding up, maybe it’s time to stop assuming that our patient is just intoxicated.